Endoscopic management of ureterovaginal fistula following hysterectomy.

Ureterovaginal fistulae are rare, and not infrequently require open surgery for correction. We describe the management of ureterovaginal fistulas utilizing retrograde double J ureteral stent placement. Four cases of ureterovaginal fistula presented between December 2002 and June 2003. Diagnosis was made by history, physical exam, intravenous pyelogram (IVP), and retrograde pyelogram. All patients underwent cystourethroscopy with indwelling double J ureteral stent and urethral Foley catheter placement. A Foley catheter was left indwelling to minimize stent reflux. The ureteral stent was removed approximately 6 weeks after dryness was reported. All patients underwent IVP or renal ultrasound at 1 month, 3 months, and 6 months after stent removal to rule out stricture. Success was measured by the patients' reports of dryness and the results of follow-up imaging studies. Four women (average age 48, range 31-68) had continuous leakage at an average onset of 12 days post hysterectomy (range 0-24). Three had laparoscopic hysterectomies for benign disease and one had a transabdominal hysterectomy for stage IIIb cervical carcinoma. All had IVPs demonstrating unilateral distal ureteral obstruction. All underwent successful retrograde ureteral stent placement at an average of 32 days post hysterectomy (range 10-67 days). All patients reported dryness before the Foley catheter was removed 3 and 4 weeks after diagnosis. The ureteral stents remained for an average of 67 days (50-99). All patients are now continent and without evidence of ureteral obstruction at an average follow-up of 5 months (1-8 months). The placement of a ureteral stent in addition to short-term indwelling urethral catheterization is a viable option in the minimally invasive approach to the management of ureterovaginal fistulas. Although the urethral catheter may lessen the occurrence of stent reflux, a controlled study is the only method to determine if the success rates are improved with longer-term urethral catheterization.

Woodie J. Wilson, MD, and J. Christian Winters MD. New Orleans, LA.